Thank you for considering a career at Bon Secours Mercy Health! Summary of Primary Function/General Purpose of Position Promote the health and welfare of assigned patients as a member of Interdisciplinary Team (IDT) caring for the patient, ensuring the patient’s individual needs are identified and addressed in a timely manner. Act as patient advocate to address primary physical and social needs including assessing and linking community resources available to the patient, as well as ensuring patients assigned have timely access to services they need while respecting the rights and wishes of the patient and family. Provide care coordination services for eligible patients, supporting the ambulatory care management team to address barriers, facilitate access to clinical services, reinforce education of self-care activities and healthy behaviors, and align to appropriate community resources. Essential Functions Maintain a caseload of patients according to department policies. Identify, enroll and/or refer patients to Ambulatory Care Manager for Transitions of Care/Complex Case Management/Chronic Disease Management as appropriate based on department protocols. Support execution of developed care plans to maximize healthcare outcomes and facilitate wellness with periodic review and update according to department protocols. Perform medication review and teach-back to ensure patient understanding and ability to adhere to medical regimen. Contact patients, caregivers and families to ensure preventive services are received by assigned patients Perform patient outreach according to established protocols and document in electronic medical record. Educate patients on availability of resources for primary care and acute care along with alternative community programs and services that promote sound health, lifestyle and well-being. Provide resource management to improve care, patient experience and reduce unnecessary cost and utilization: right care, right place, and right time. Assist patient in advanced care planning to complete Advanced Directives as appropriate. Obtain and coordinate access with primary care providers and other specialty providers including behavioral health ensuring necessary records and documentation of referrals are completed and reconciled Identify, execute, and track needed referrals to care and community resources. Document all communications with patient and/or care team in electronic medical record. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. Patient Population The following must be included in all position descriptions that involve direct or indirect patient care. This is a JCAHO requirement. Also select the age of the patient population served: Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assigned unit. Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures. Neonates (0-4 weeks) Adolescents (13-17 years) Infant (1-12 months) Adults (18-64 years). Pediatrics (1-12 years) Geriatrics (65 years and older) Employment Qualifications Required Minimum Education: High School Diploma Licensing/ Certification Licensure/Certification Required Licensed Practical or Vocational Nurse with active License in State of Patient Care Licensure/Certification Preferred Multi-sate nursing license Community Health Worker certification or working toward certification, Certified Health Coach Minimum Qualifications Minimum Years and Type of Experience 2 years experience in community based setting, home health or case management experience Other Knowledge, Skills and Abilities Required Excellent interpersonal communication and negotiation skills. Strong analytical, data management and computer skills. Demonstrate basic knowledge of healthcare and health education across the lifespan in a practice health setting. Ability to work with individuals, groups and families. Familiarity and knowledge of Community Resources. Flexibility to work non- traditional hours. Works well in a Team Setting. Personal computer skills. Experience with database entry, EMR documentation, Power Point preferred and basic Excel skills. Highly organized and detail oriented. Accepts responsibility and follows through on projects and activities Other Knowledge, Skills and Abilities Preferred Demonstrated success in improving the health of a distinct population of patients in the ambulatory or community setting. Experience in a healthcare related environment working with patients, families, and providers. Preferred knowledge of managed care requirements both public and private Bon Secours Mercy Health is an equal opportunity employer. Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status Scheduled Weekly Hours: 40 Work Shift: Days (United States of America) Department: Care Coordination - Population Health Service Organization All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you’d like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com. For nearly 200 years, the historical founders of Bon Secours Mercy Health has been providing care to those in need. Today, the ministry is one of the top 20 health systems in the United States and part of the top performing quartile of Catholic health systems for lowest cost per case for patient care. This quality care is provided by more than 57,000 employees serving communities throughout Florida, Kentucky, Maryland, New York, Ohio, South Carolina and Virginia. The health care ministry provided care for patients more than 10.3 million times in 2017 through its network of more than 1,000 care sites. Consistent with its commitment to serve each patient with dignity, Bon Secours Mercy Health provides nearly $2 million per day in community benefit. The Mission of Bon Secours Mercy Health is to extend the compassionate ministry of Jesus by improving the health and well-being of its communities and bring good help to those in need, especially people who are poor, dying and underserved. For more information, visit www.bsmhealth.org.